SAMBA Talks eNewsletter - April, 2004

Comparison of Recovery Profile After Ambulatory Anesthesia with Propofol, Isoflurane, Sevoflurane and Desflurane: A Systematic Review
Anil Gupta, MD FRCA, PhD, Tracey Stierer, MD, Rhonda Zuckerman, MD, Neal Sakima, MD, Stephen D. Parker, MD, and Lee A. Fleisher, MD
Anesth Analg 2004;98:632-641

In this systematic review we focused on postoperative recovery and complications using four different anesthetic techniques. The database MEDLINE was searched via PubMed (1966 to June 2002) using the search words "anesthesia" and with ambulatory surgical procedures limited to randomized controlled trials in adults (>19 yr), in the English language, and in humans. A second search strategy was used combining two of the words "propofol," "isoflurane," "sevoflurane," or "desflurane". Screening and data extraction produced 58 articles that were included in the final meta-analysis. No differences were found between propofol and isoflurane in early recovery. However, early recovery was faster with desflurane compared with propofol and isoflurane and with sevoflurane compared with isoflurane. A minor difference was found in home readiness between sevoflurane and isoflurane (5 min) but not among the other anesthetics. Nausea, vomiting, headache, and postdischarge nausea and vomiting incidence were in favor of propofol compared with isoflurane (P < 0.05). A larger number of patients in the inhaled anesthesia groups required antiemetics compared with the propofol group. We conclude that the differences in early recovery times among the different anesthetics were small and in favor of the inhaled anesthetics. The incidence of side effects, specifically postoperative nausea and vomiting, was less frequent with propofol.
IMPLICATIONS: A systematic analysis of the literature comparing postoperative recovery after propofol, isoflurane, desflurane, and sevoflurane-based anesthesia in adults demonstrated that early recovery was faster in the desflurane and sevoflurane groups. The incidence of nausea and vomiting were less frequent with propofol.

The Influence of Ambulation Time on the Incidence of Transient Neurologic Symptoms After Lidocaine Spinal Anesthesia
Martti Silvanto, MD, Pekka Tarkkila, MD, PhD, Marja-Leena Mäkelä, MD, and Per H. Rosenberg, MD, PhD
Anesth Analg 2004;98:642-646

The cause of transient neurologic symptoms (TNSs) after lidocaine spinal anesthesia remains unclear. It has been proposed that early ambulation after spinal anesthesia contributes to the development of TNSs. We evaluated the influence of ambulation time on the occurrence of TNSs after spinal anesthesia with 50 mg of 2% plain lidocaine for knee arthroscopy. One-hundred-twenty patients undergoing knee arthroscopy (ASA physical status 1–2) were randomized into 3 groups, i.e., early (Group E), 6-h (Group 6-h), or late ambulation (Group L) groups. In Group E, ambulation was allowed as early as possible after regression of spinal block (on average 229 ± 21 min; range, 135–247 min). In Group 6-h, the patients remained in bed for approximately 6 h after the block and in Group L until the next morning. The patient groups were comparable with respect to demographic, anesthetic, and surgical variables. The overall incidence of TNSs was 16%. TNSs occurred in 3 patients of Group E (7.5%), in 11 patients of Group 6-h (28%), and in 5 patients of Group L (13%). No significant differences were detected between the patients with and without TNSs. Early ambulation was not found to be a risk factor for TNSs after spinal anesthesia with 50 mg of 2% lidocaine.
IMPLICATIONS: This study shows that early ambulation time does not increase the incidence of transient neurologic symptoms after spinal anesthesia with 50 mg of 2% lidocaine for elective knee arthroscopy.

Pretreatment with Thiopental for Prevention of Pain Associated with Propofol Injection
Anil Agarwal, MD, Mohammad F. Ansari, MD, Devendra Gupta, MD, Ravindra Pandey, MD, Mehdi Raza, MD, Prabhat K. Singh, MD, Shiopriye, MBBS, Sanjay Dhiraj, MD, and Uttam Singh, PhD
Anesth Analg 2004;98:683-686

Propofol causes pain on IV injection in 28%–90% of patients. A number of techniques have been tried to minimize propofol-induced pain, with variable results. We compared the efficacy of pretreatment with thiopental 0.25 mg/kg and 0.5 mg/kg and lidocaine 40 mg after venous occlusion for prevention of propofol-induced pain. One-hundred-twenty-four adult patients, ASA physical status I–II, undergoing elective surgery were randomly assigned into 4 groups of 31 each. Group I received normal saline, group II received lidocaine 2% (40 mg), and groups III and IV received thiopental 0.25 mg/kg and 0.5 mg/kg, respectively. All pretreatment drugs were made in 2 mL and were accompanied by manual venous occlusion for 1 min. Propofol was administered after release of venous occlusion. Pain was assessed with a four-point scale: 0 = no pain, 1 = mild pain, 2 = moderate pain, and 3 = severe pain at the time of propofol injection. Twenty-four patients (77%) complained of pain in the group pretreated with normal saline as compared with 12 (39%), 10 (32%), and 1 (3%) in the groups pretreated with lidocaine 40 mg, thiopental 0.25 mg/kg, and thiopental 0.5 mg/kg, respectively (P < 0.05). Thiopental 0.5 mg/kg was the most effective treatment. We therefore suggest routine pretreatment with thiopental 0.5 mg/kg along with venous occlusion for 1 min for prevention of pain associated with propofol injection.
IMPLICATIONS: Pain associated with IV injection of propofol is seen in 28%–90% patients. Pretreatment with thiopental 0.25 mg/kg and 0.5 mg/kg after manual venous occlusion for 1 min effectively attenuated pain associated with propofol injection. Thiopental 0.5 mg/kg was the most effective in prevention of propofol pain and can be used routinely.

Is Physician Anesthesia Cost-Effective?
J. P. Abenstein, MSEE MD, Kirsten Hall Long, PhD, Brian P. McGlinch, MD, and Niki M. Dietz, MD
Anesth Analg 2004;98:750-757

One of the most controversial issues in anesthesia is whether nonmedically directed nurse anesthetists are relatively more cost-effective than anesthesiologists in the provision of anesthesia care. We electronically surveyed anesthesia practices throughout the United States to estimate the range in anesthesia professional costs from the payer perspective. Using this survey data on anesthesia reimbursement and published outcomes studies, we developed an ad hoc model to estimate the cost-effectiveness of physician-directed anesthesia relative to a nonmedically directed nurse anesthetist model of care from the payer perspective. Cost-effectiveness ratios were defined as the ratio of incremental costs associated with physician anesthesia relative to the estimated incremental life expectancy gains with this model of care (i.e., dollars per year of life saved [$/YLS]). Reference case results suggest that physician anesthesia is cost saving with an estimated incremental cost-effectiveness ratio of -$2,601/YLS for a younger privately insured patient and an estimated cost-effectiveness ratio of -$4,410/YLS for an elderly Medicare insured patient. Cost-effectiveness ratios ranged from -$4,410 to $38,778/YLS in univariate and multivariate sensitivity analyses across payer types. Results were most sensitive to assumed differences in reimbursement (commercial conversion factors) and to mortality rate assumptions by provider type. This analysis offers economic evidence in support of the physician anesthesia model of care.
IMPLICATIONS: Recent outcome studies suggest improved patient outcomes when physicians medically direct nurse anesthetists versus anesthesia care delivered with nonmedically directed nurses. The relative cost-effectiveness of this practice model is, however, unknown. This economic analysis suggests that outcome gains with physician anesthesia may be obtained at cost savings or, under conservative assumptions, at a cost deemed reasonable by society.

When to Release Allocated Operating Room Time to Increase Operating Room Efficiency
Franklin Dexter, MD PhD, and Alex Macario, MD MBA
Anesth Analg 2004;98:758-762

We studied when allocated, but unfilled, operating room (OR) time of surgical services should be released to maximize OR efficiency. OR time was allocated for two surgical suites based on OR efficiency. Then, we analyzed real OR schedules. We added new hypothetical cases lasting 1, 2, or 3 h into OR time of the service that had the largest difference between allocated and scheduled cases (i.e., the most unfilled OR time) 5 days before the day of surgery. The process was repeated using the updated OR schedule available the day before surgery. The pair-wise difference in resulting overutilized OR time was calculated for n = 754 days of data from each of the two surgical suites. We found that postponing the decision of which service gets the new case until early the day before surgery reduces overutilized OR time by <15 min per OR per day as compared to releasing the allocated OR time 5 days before surgery. These results show that when OR time is released has a negligible effect on OR efficiency. This is especially true for ambulatory surgery centers with brief cases or large surgical suites with specialty-specific OR teams. What matters much more is having the correct OR allocations and, if OR time needs to be released, making that decision based on the scheduled workload.
IMPLICATIONS: Provided operating room (OR) time is allocated and cases are scheduled based on maximizing OR efficiency, then whether OR time is released five days or one day before the day of surgery has a negligible effect on OR efficiency.

Adding Dexmedetomidine to Lidocaine for Intravenous Regional Anesthesia
Dilek Memi , MD, Alparslan Turan, MD, Beyhan Karamanllu, MD, Zafer Pamukçu, MD, and Imran Kurt, MD
Anesth Analg 2004;98:835-840

Dexmedetomidine is approximately 8 times more selective toward the -2-adrenoceptors than clonidine. It decreases anesthetic requirements by up to 90% and induces analgesia in patients. We designed this study to evaluate the effect of dexmedetomidine when added to lidocaine in IV regional anesthesia (IVRA). We investigated onset and duration of sensory and motor blocks, the quality of the anesthesia, intraoperative-postoperative hemodynamic variables, and intraoperative-postoperative pain and sedation. Thirty patients undergoing hand surgery were randomly assigned to 2 groups to receive IVRA. They received 40 mL of 0.5% lidocaine and either 1 mL of isotonic saline (group L, n = 15) or 0.5 µg/kg dexmedetomidine (group LD, n = 15). Sensory and motor block onset and recovery times and anesthesia quality were noted. Before and after the tourniquet application at 5, 10, 15, 20, and 40 min, hemodynamic variables, tourniquet pain and sedation, and analgesic use were recorded. After the tourniquet deflation, at 30 min, and 2, 4, 6, 12, and 24 h, hemodynamic variables, pain and sedation values, time to first analgesic requirement, analgesic use, and side effects were noted. Shortened sensory and motor block onset times, prolonged sensory and motor block recovery times, prolonged tolerance for the tourniquet, and improved quality of anesthesia were found in group LD. Visual analog scale scores were significantly less in group LD in the intraoperative period and 30 min, and 2, 4, and 6 h after tourniquet release. Intra-postoperative analgesic requirements were significantly less in group LD. Time to first analgesic requirements was significantly longer in group LD in the postoperative period. We conclude that the addition of 0.5 µg/kg dexmedetomidine to lidocaine for IVRA improves quality of anesthesia and perioperative analgesia without causing side effects.
IMPLICATIONS: This study was designed to evaluate the effect of dexmedetomidine when added to lidocaine for IV regional anesthesia. This is the first clinical study demonstrating that the addition of 0.5 µg/kg dexmedetomidine to lidocaine for IV regional anesthesia improves quality of anesthesia and intraoperative-postoperative analgesia without causing side effects.

ACTA ANAESTHESIOLOGICA SCANDINAVICA - TOP

Continuous popliteal sciatic nerve block for outpatient foot surgery - a randomized, controlled trial
Zaric D, Boysen K, Christiansen J, Haastrup U, Kofoed H, Rawal N.
Acta Anaesthesiol Scand. 2004 Mar;48(3):337-41.

Background: A major problem in outpatient foot surgery is severe postoperative pain that is not sufficiently treated by peroral analgesics.
Methods: Sixty-three patients underwent foot surgery under spinal anesthesia. Immediately on conclusion of the operation, sciatic and saphenous nerve blocks were performed. The sciatic nerve was blocked in the popliteal fossa with 30 ml of ropivacaine 5 mg ml(^-1) and a perineural catheter was passed through the cannula. The patients were randomized to receive either ropivacaine 2 mg ml(^-1) (n=30) or saline (n=30) in the catheter through a disposable elastomeric pump with a fixed infusion rate of 5 ml h(^-1) for 55 h.
Results: Analgesia was excellent until 23 h 44 min (14 h 34 min) in the treatment group and 18 h 16 min (7 h) in the placebo group [mean (SD), P=0.07]. Thereafter, pain was significantly less in the treatment group on the first and second postoperative days (P=0.001). Sleep disturbances because of the pain in the foot were experienced by 25% of the treatment group on the first night at home and by 50% of the control group (P=0.29). There were no differences between the groups in their need for rescue opioid medication. None of the patients had any major problem with the catheter or pump, and none had any toxic effect referable to the technique.
Conclusion: This randomized, double-blind study shows that continuous blockade of the sciatic nerve in the popliteal fossa reduces postoperative pain and has no untoward effects in a patient group known to experience severe pain after ambulatory surgery.

Inclusion of epinephrine to hyperbaric tetracaine and the supine position enhance the cephalad spread of spinal anaesthesia compared with hyperbaric tetracaine alone in the lithotomy position
S. Inoue, Y. Kawaraguchi, K. Kitaguchi, H. Furuya
Acta Anaesthesiol Scand. 2004;48(3):342-6.

Background: Intrathecal epinephrine can produce prolongation of duration of spinal anaesthesia by reducing vascular absorption of the local anaesthetics. The patient's positioning can change the cephalad spread of hyperbaric local anaesthetics by affecting the lordosis of the vertebral canal. These factors combined are expected to affect the cephalad spread of sensory block levels. The purpose of this study was to investigate whether combined use of epinephrine with hyperbaric tetracaine in the supine position can enhance the cephalad spread of sensory block levels compared with hyperbaric tetracaine alone in the lithotomy position.
Methods: ASA physical status I or II 48 urological (lithotomy group) and 48 orthopaedic patients (supine group) scheduled to undergo elective surgical procedures in the lithotomy or supine position under spinal anaesthesia were enrolled. Patients in each group were randomly divided into two subgroups to receive intrathecal 10 mg of hyperbaric tetracaine with or without 0.2 mg of epinephrine (Groups L, LE, S, and SE). The extent of sensory blockade was assessed by loss of cold sensation. After achievement of sensory blockade up to T10, the patients in Groups L and LE were immediately placed in the lithotomy position. Patients in Groups S and SE were maintained in the supine position.
Results: The highest sensory blockade in the SE Group was on average statistically significantly higher than in the L Group. The mean time taken to the highest sensory blockade in the SE Group was statistically significantly longer than in Groups L and S. Atropine for bradycardia was used more frequently in the SE Group than in the other groups. Conclusions: Combined use of epinephrine with hyperbaric tetracaine in the supine position can enhance the cephalad spread of sensory block levels compared with hyperbaric tetracaine alone in the lithotomy position.

Comparison of 27-gauge (0.41-mm) Whitacre and Quincke spinal needles with respect to post-dural puncture headache and non-dural puncture headache
Santanen U, Rautoma P, Luurila H, Erkola O, Pere P.
Acta Anaesthesiol Scand. 2004; 48(4):474-9.

Background: The incidence of headache after spinal anaesthesia has varied greatly between studies. We compared the incidence of postoperative headache in general and postdural puncture headache (PDPH) when using 27-gauge (G) (outer diameter 0.41 mm) Quincke and Whitacre spinal needles in ambulatory surgery performed under spinal anaesthesia.
Methods: In a prospective, randomized study, 676 ASA physical status I-II day-case outpatients were given a spinal anaesthetic through either a 27-G (0.41 mm) Quincke or a 27-G (0.41 mm) Whitacre spinal needle. The incidence of any type of postoperative headache was assessed and the type of headache defined using a standardized questionnaire including PDPH criteria. The severity of the headache was defined using a 100-mm visual analogue scale.
Results: For the final analysis, 529 patients were available (259 patients in the Quincke group and 270 patients in the Whitacre group). The overall incidence of postoperative headache was 20.0%, but the incidence of true PDPH was very low (1.51%). The incidence of PDPH in the Quincke group was 2.70%, while in the Whitacre group it was only 0.37% (P < 0.05). The overall incidence of non-dural puncture headache was 18.5% and did not differ between the study groups.
Conclusions: True PDPH seldom occurs when a 27-G (0.41 mm) spinal needle is used, although postoperatively a non-specific headache is common. Using the 27-G (0.41 mm) Whitacre spinal needle further reduced the incidence of PDPH. Thus, we recommend routine use of the 27-G (0.41 mm) Whitacre spinal needle when performing spinal anaesthesia.

Analgesia and discharge following preincisional ilioinguinal and iliohypogastric nerve block combined with general or spinal anaesthesia for inguinal herniorrhaphy
J. Toivonen, J. Perm and P. H. Rosenberg
Acta Anaesthesiologica Scandinavica 2004;48(4): 480-5

Background: Preincisional ilioinguinal and iliohypogastric nerve block (IINB) reduces postoperative analgesics after inguinal herniorrhaphy. The effect of an IINB on postoperative pain and discharge profile was therefore studied in day-surgery patients undergoing inguinal herniorrhaphy with general or spinal anaesthesia.
Methods: Seventy ASA I-II adult patients scheduled for inguinal herniorrhaphy received an IINB before the surgical incision with 15 ml of 0.5% bupivacaine. In a randomized fashion half of them received general anaesthesia with spontaneous breathing via a laryngeal mask (GA-group) and the other half received spinal anaesthesia with 5 mg of bupivacaine diluted with sterile water to 2.5-ml volume (SPIN-group). In the postanaesthesia care unit (PACU), pain was assessed on a scale from 0 to 10 (VAS) and ketorolac 30 mg i.v. (VAS < 5), or fentanyl 0.05 mg i.v. (VAS ≥ 5) was administered as scheduled. In the day surgery unit and at home the analgesic was a tablet of ibuprofen 200 mg + codeine 30 mg (VAS ≥ 3).
Results: Patients in the SPIN-group reported lower postoperative pain scores at 30, 60 min (P < 0.0001) and 120 min (P < 0.05) after surgery, and longer time to first analgesic use (P < 0.0001). Patients in the GA-group had a shorter time to discharge without voiding (P < 0.001) and with voiding (P < 0.05). After discharge, there were no significant differences between the groups regarding pain scores at rest and at walking, or the doses of analgesic. Adverse events were rare in both groups.
Conclusion: Only a relatively short immediate analgesic benefit could be demonstrated by a combination of IINB with spinal anaesthesia compared with IINB combined with general anaesthesia. The use of general anaesthesia facilitated an earlier postoperative discharge than spinal anaesthesia.

Bilateral hypoglossal nerve injury following the use of the laryngeal mask without the use of nitrous oxide (CASE REPORT)
Sommer, M. Schuldt, U. Runge, S. Gielen-Wijffels, M. A. E. Marcus
Acta Anaesthesiol Scand. 2004;48(3):377-8

Hypoglossal nerve injury is a rare complication of anaesthesia airway management in adults. Until now the use of nitrous oxide for anaesthesia supposedly contributed to this complication. We present a case of bilateral hypoglossal nerve injury following the use of a laryngeal mask airway without the use of nitrous oxide.

At the conclusion of 3 h of surgery in extreme side rotation, a 15-year-old boy of 88 kg could not extend his tongue beyond his teeth. An MRI confirmed the absence of pharyngeal haematoma and the absence of thrombosis of the basilar artery.

We conclude that even when patients have no medical history and nitrous oxide is not being used, prolongation of the operation in an extreme position might increase the risk of major complications with a laryngeal mask.

BRITISH JOURNAL OF ANAESTHESIA - TOP

Development of a difficulty score for spinal anaesthesia
M. M. Atallah, A. D. Demian and A. A. Shorrab
Br J Anaesth 2004; 92: 354–60

Background. Multiple attempts at spinal puncture may be hazardous. Accurate preoperative prediction of difficulty adds to the delivery of high quality care. This clinical trial was designed to: (i) determine the predictive performance of difficulty variables; (ii) compare senior and junior anaesthetists; (iii) develop a score to predict difficulty during the performance of spinal anaesthesia.
Methods. A total of 300 patients subjected to urological procedures and scheduled for spinal anaesthesia were independently assessed and stratified according to the categories of the difficulty predictors of spinal anaesthesia into one of nine grades (0–8) and randomized according to the experience of the anaesthetist into two groups (group A, staff with more than 15 yrs’ experience; group B, resident with more than 6 months but less than 1 yr in training). The number of attempts and levels, and success rate of the technique were the outcome variables. Data were analysed by multivariate analysis and receiver operating characteristic (ROC) curves.
Results. The bony landmarks of the back and the radiological characteristics of the lumbar vertebrae were two independent predictors of difficulty. Multivariate analysis indicated differences between junior and senior staff but ROC curves indicated no difference. Grade 4 was the difficulty score at or above which difficulty was expected whether or not radiological characteristics of the vertebrae were included.
Conclusions. Spinal bony landmarks and radiological characteristics of the lumbar vertebrae are independent predictors of difficulty during spinal anaesthesia. There is no difference between senior and junior anaesthetists. Grade 4 is the difficulty score at or above which difficulty is expected.

Analgesia for day-case shoulder surgery
A. T. Wilson, E. Nicholson, L. Burton and C. Wild
Br J Anaesth 2004; 92: 414–15

Background. Single-shot nerve blocks provide excellent postoperative analgesia for a limited period and are increasingly used in day-case units. They allow early patient discharge following painful operative procedures that would otherwise require overnight hospitalization. We investigated the adequacy of analgesia at home after the block had worn off.
Methods. A prospective audit by telephone 1 week after surgery of 50 consecutive patients who had had a single-shot interscalene block for day-case shoulder arthroscopic surgery.
Results. The mean length of adequate sensory block was 22.5 h (9–48 h) after which 20% of patients had a maximum visual analogue scale (VAS) score of 5/5. Most patients did not take analgesics as prescribed and two patients (5.4%) required additional analgesia from their family doctor or accident and emergency department.
Conclusions. We conclude that analgesia at home is often inadequate after painful day-case surgical procedures if single-shot local anaesthetic blockade is used.

CANADIAN JOURNAL OF ANESTHESIA - TOP

Desflurane does not accelerate recovery from operations of short duration: a practice audit
Michael J. Tessler, MD, Antoine G. Rochon, MD and Ian Shrier, MD PhD
Canadian Journal of Anesthesia 51:222-225 (2004)

Purpose: Desflurane, a newer inhalation anesthetic agent, has been promoted as a superior drug because patients will awaken sooner after anesthesia. This has only been proven in operations of long duration (i.e., more than one hour). We assessed our experience using desflurane in short out-patient surgery with a retrospective analysis of a single surgeon’s elective laparoscopic cholecystectomy patients.
Methods: With Institutional consent, we performed a retrospective comparison of the postoperative recovery of patients who received desflurane/air/oxygen to historical control patients who received isoflurane/N₂O/oxygen.
Results: Patient preoperative characteristics were similar in the two groups. Duration of surgery and the time from the end of surgery to patient leaving the operating room for the desflurane and isoflurane/N₂O groups were (in minutes) 42.7 ± 13.5 and 9.6 ± 4.6 vs 47.2 ± 15.1 and 8.5 ± 4.1 respectively (P = NS). Total Aldrete scores upon presentation to the postanesthesia care unit (PACU) were 8.1 ± 1.4 and 7.9 ± 1.8 for the two groups respectively (P = NS). The percentage of patients who arrived in the PACU with consciousness scores of 2, 1, 0 for the desflurane and isoflurane/N₂O groups were 20.4, 75.5, and 4.1 vs 14.6, 73.2 and 12.2 respectively (P = NS). Mean length of stay in the PACU for the two groups was 160 ± 111 and 156 ± 114 min (P = NS).
Conclusion: Our results show that in short procedures the use of desflurane does not necessarily result in faster patient recovery or discharge from the PACU.

PUB MED - TOP

Comparison of prophylactic anti-emetic effects of ondansetron and dexamethasone in women undergoing day-case gynaecological laparoscopic surgery
Yuksek MS, Alici HA, Erdem AF, Cesur M.
J Int Med Res. 2003 Nov-Dec;31(6):481-8

We aimed to determine the effect of ondansetron and dexamethasone on preventing post-operative nausea and vomiting (PONV). Sixty women undergoing laparoscopic gynaecological surgery were randomized to receive ondansetron 4 mg, dexamethasone 8 mg or saline. Drugs were administered 2 min before induction of anaesthesia, and anaesthesia and post-operative analgesic regimens were standardized. The incidence of PONV in the first 24 h after the operation was 35% in the ondansetron group, 55% in dexamethasone group and 85% in the control group. A significant difference between the groups was only seen in the first 3 h post-operatively. In this period, ondansetron was significantly more effective than dexamethasone and saline, but no differences were seen between dexamethasone and saline. In all treatment groups, post-operative visual analogue scale scores, sedation scores and usage of analgesics were similar. In conclusion, ondansetron, but not dexamethasone, prevented PONV in the first 3 h after gynaecological laparoscopic surgery.

Routine day-case laparoscopic cholecystectomy
Leeder PC, Matthews T, Krzeminska K, Dehn TC
Br J Surg. 2004 Mar;91(3):312-6

BACKGROUND: A prospective study was carried out to assess the feasibility of performing true day-case laparoscopic surgery in a district general hospital.
METHODS: All patients admitted consecutively under the care of one surgeon for laparoscopic cholecystectomy were included in the study. Selection criteria for a day-case procedure included an American Society of Anesthesiologists grade of I or II and the availability of a responsible caretaker at home. Patients were discharged 4-6 h after surgery with a standard analgesia pack and a contact number for advice. All patients were contacted by telephone on the day after discharge. A postal questionnaire was sent to the first 100 patients to assess satisfaction with the day-case process.
RESULTS: Of 357 patients admitted for laparoscopic cholecystectomy over a 24-month period, 154 (43.1 per cent) were operated on as day cases on a morning theatre list. Twenty-two patients required an overnight stay (14.3 per cent), three because of conversion to an open procedure. One patient was readmitted for neck pain. Eighty-two (92.1 per cent) of 89 patients were either satisfied or very satisfied with the day-case procedure.
CONCLUSION: This study has demonstrated a low rate of overnight stay (14.3 per cent) and readmission (1.9 per cent), and a high degree of patient satisfaction for day-case laparoscopic cholecystectomy.

Anesthesia technique for outpatient facial laser resurfacing
Ramos-Zabala A, Perez-Mencia MT, Fernandez-Garcia R, Cascales-Nunez MR.
Lasers Surg Med. 2004;34(3):269-72

BACKGROUND AND OBJECTIVES: Multiple anesthetic approaches exist for full-face laser resurfacing. The purpose of this study was to describe an anesthesia technique based on combination of eutectic mixture local anesthetics (EMLA) and remifentanil sedation, that can be utilized by anesthesiologists in the ambulatory environment.
STUDY DESIGN/MATERIALS AND METHODS : Fifty patients elected for facial laser resurfacing. All patients received topical anesthesia in full face with EMLA cream at 60 minutes (min) before laser procedure. On arrival at the operating room, intravenous (IV) sedation was administered with remifentanil (0.20 mcg/kg/minute), midazolam (1.5- 2 mg bolus IV), and propofol infusion (0.5-1 mg/kg/hour). The subsequent infusion rate of remifentanil was varied to maintain an adequate level of sedation and analgesia. Five minutes before the operation conclusion, the sedation infusion was discontinued. Patients were discharged after achieving a minimum criteria for recovery.
RESULTS: Almost all the patients were successfully anesthetized by this combination technique, only four patients needed complementary anesthesia with regional nerve blockade. The mean level of sedation scored 2-3 on the Ramsay scale. The mean discharge time was 55 minutes. No complications were observed.
CONCLUSIONS: The use of a combination of topical EMLA anesthesia and IV conscious sedation based on remifentanil provided an adequate depth of anesthesia for outpatient facial laser resurfacing without complications.

Ambulatory perineural infusion: the patients' perspective.
Ilfeld BM, Esener DE, Morey TE, Enneking FK.
Regional Anesthesia & Pain Medicine. 28(5):418-23, 2003 Sep-Oct

BACKGROUND AND OBJECTIVES: Ambulatory perineural local anesthetic infusion is a relatively new method for providing postoperative analgesia, and many aspects of this technique remain in the domain of conjecture and speculation. This retrospective chart review and survey was undertaken to investigate patients' opinions on various aspects of their ambulatory perineural infusion experience.
METHODS: Patients who had received an ambulatory perineural infusion from the University of Florida were identified via pharmacy records. Patients were contacted by phone and were asked various questions regarding their experiences and preferences during and after their perineural infusion.
RESULTS: Of 217 patients identified, 215 charts were located and retrieved. Of these, 137 (64%) were successfully contacted and 131 (61%) consented to take part in the survey. More than 97% of patients reported that they felt "safe" during home infusion, that one physician telephone call each night was optimal contact, and that they were comfortable removing the catheter with instructions given over the phone. Only 4% would have preferred to return for catheter removal, and 43% felt that they would have been comfortable with only written instructions for catheter removal.
CONCLUSION: This investigation suggests that perineural local anesthetic infusion isgenerally well tolerated by ambulatory patients.

Anesthesia for ambulatory anorectal surgery
Gudaityte J, Marchertiene I, Pavalkis D.
Medicina ( Kaunas). 2004;40(2):101-11

The prevalence of minor anorectal diseases is 4-5% of adult Western population. Operations are performed on ambulatory or 24-hour stay basis. Requirements for ambulatory anesthesia are: rapid onset and recovery, ability to provide quick adjustments during maintenance, lack of intraoperative and postoperative side effects, and cost-effectiveness. Anorectal surgery requires deep levels of anesthesia. The aim is achieved with 1) regional blocks alone or in combination with monitored anesthesia care or 2) deep general anesthesia, usually with muscle relaxants and tracheal intubation. Modern general anesthetics provide smooth, quickly adjustable anesthesia and are a good choice for ambulatory surgery. Popular regional methods are: spinal anesthesia, caudal blockade, posterior perineal blockade and local anesthesia. The trend in regional anesthesia is lowering the dose of local anesthetic, providing selective segmental block. Adjuvants potentiating analgesia are recommended. Postoperative period may be complicated by: 1) severe pain, 2) urinary retention due to common nerve supply, and 3) surgical bleeding. Complications may lead to hospital admission. In conclusion, novel general anesthetics are recommended for ambulatory anorectal surgery. Further studies to determine an optimal dose and method are needed in the group of regional anesthesia.

Cataract surgery in a patient with severe obstructive sleep apnea syndrome
Reber A, Ursprung T.
Anaesthesist. 2003 Nov;52(11):1027-30

This case report describes airway management during cataract surgery for a patient with known severe obstructive sleep apnea syndrome. Surgery could not be performed using a pure local anesthetic procedure because of the psychological history of the patient. In consideration of the severity of the patient's sleep apnea syndrome, we chose an anesthetic procedure that would compromise the upper airway as little as possible. For respiratory strategy, the patient's own nasal CPAP (continuous positive airway pressure) equipment was used. Anesthesia was maintained with continuous infusion of propofol and remifentanil while the patient was breathing spontaneously. The patient was transferred to the recovery room where nasal CPAP was continued for 1 h until the patient was returned to the ward.

Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesia
Habib NE, Mandour NM, Balmer HG.
J Cataract Refract Surg. 2004 Feb;30(2):437-43

Purpose: To study the effect of sedation on patients' anxiety level and perception of pain during cataract surgery under topical anesthesia.
Setting: Royal Eye Infirmary, Plymouth, England.
Methods: This prospective controlled double-blind clinical trial comprised 100 consecutive patients having routine phacoemulsification with posterior chamber intraocular lens implantation under topical anesthesia by a single experienced surgeon. Patients were randomized to receive intravenous midazolam (0.015 mg/kg body weight) 15 minutes before surgery or no sedation. The main evaluation criteria were the anxiety based on the 6-item, short form of the State-Trait Anxiety Inventory, the pain score using a visual analog scale, and overall patient satisfaction.
Results: All operations were uneventful, and no side effects were noted from the use of midazolam. Anxiety scores were significantly higher on arrival at the hospital than just before the commencement and after the conclusion of the surgery in both groups (P<.05). Patients were less anxious after administration of midazolam, but this did not achieve statistical significance. The mean pain score was 0.29 (range 0 to 4) in the sedation group and 0.38 (range 0 to 4) in the control group; the difference between groups was not statistically significant. The patients were equally satisfied in both groups, with mean scores of 3.84 (range 0 to 4) and 3.88 (range 2 to 4), respectively.
Conclusions: Patients who had cataract surgery under topical anesthesia were highly satisfied with their operative experience and reported minimal pain during surgery. Anxiety levels diminished after arrival at the hospital, possibly because of reassurance by experienced staff. Intravenous midazolam did not seem to significantly reduce pain or anxiety.

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